A pulmonary artery catheter is used to monitor hemodynamics perioperatively in cardiac surgery patients, but a pulmonary artery catheter is not recommended in all patients undergoing cardiac surgery because of the potential for severe complications. We report a case of ventricular fibrillation induced by insertion of a pulmonary artery catheter during emergency surgery for acute aortic dissection with extension to the origin of the right coronary artery that required defibrillation. The cause of ventricular fibrillation was thought to be contact of the pulmonary artery catheter with the right ventricular lumen, which was highly irritable due to ischemia resulting from the decrease in perfusion pressure of the right coronary artery. A pulmonary artery catheter should be placed in patients with acute right ventricular ischemia only after considering and evaluating the risk of ventricular fibrillation.

Myotonic dystrophy is associated with arrhythmia and malignant hyperthermia, which can be problematic for anesthesia management. A 1-year, 8-month-old boy, 82 cm tall and weighing 7 kg, was scheduled for undescended testicle fixation after diagnosis of cryptorchidism. He was born at 31 weeks and 6 days with a birth weight of 2,075 g and an APGAR score of 2-5. He had ventricular tachycardia and cardiac arrest on days 143 and 146. Anesthesia was planned as total intravenous anesthesia. The defibrillation pads were placed, the airway was secured with a supraglottic device, and sacral epidural anesthesia was performed. The patient was discharged from the hospital on the fourth postoperative day without any complications. A patient with myotonic dystrophy who had a history of fatal arrhythmia was safely anesthetized by assessing his disease status and planning appropriate anesthetic management.

One-lung ventilation in patients with laryngeal cancer can be challenging with respect to airway management. In this report, we describe a successful one-lung ventilation using a combination of a supraglottic device and a bronchial blocker for lung lobectomy in a patient with a vocal cord tumor. Prior placement of a bronchial blocker into the trachea using a video laryngoscope facilitated the subsequent insertion of the supraglottic device without injury to the vocal cord tumor. Intraoperative airway management and the patient’s postoperative course were uneventful. The combination of a supraglottic device and a bronchial blocker may be a useful alternative to avoid injury to the vocal cord tumor by using a thin blocker tube instead of double- or single-lumen tubes.

Background : Remimazolam is an ultra-short-acting benzodiazepine with minimal circulatory depressant effects. However, its safety in cardiac surgery in patients with low cardiac function complicated by low flow, low gradient aortic stenosis(LFLG-AS)has not yet been reported. We herein report a case of LFLG-AS in which stable circulation was maintained with remimazolam in a combined off pump coronary artery bypass grafting(OPCAB)and transfemoral transcatheter aortic valve implantation(TFTAVI)surgery.

Case presentation : An 80-year-old man with ischemic cardiomyopathy and LFLG-AS required coronary artery bypass grafting and aortic valve replacement. To avoid weaning from cardiopulmonary bypass, a joint OPCAB and TFTAVI surgery was scheduled, and intravenous anesthesia with remimazolam, which causes less circulatory depression than conventional anesthetics, was selected. Intraoperative noradrenaline and dobutamine were used as needed, and the surgery was completed without major circulatory depressant effects.

Conclusions : In the current case, remimazolam did not significantly affect circulatory depression and could be safely used in combined OPCAB and TFTAVI surgery for an LFLG-AS patient.

Kagoshima Prefectural Oshima Hospital is located on a remote island with limited medical resources. Thus, in response to the sixth wave of coronavirus disease-2019（COVID-19）, we strengthened the infection control measures in our operating rooms through 1）quantitative antigen testing in patients within 3 days prior to the operation date；2）patient isolation and postponing the date of surgery until after the isolation period has lifted except for emergency cases；3）zoning in the operating department；4）opening the lobby of the operating room for patients with COVID-19 to the public outside the building when operating on patients with COVID-19；5）wearing full personal protective equipment（PPE）during aerosol-generating procedures when interacting with patients with confirmed COVID-19 and using standard PPE and N95 respirators for other patients；and 6）limiting the number of people in the operating room during intubation and extubation. There was no evidence of COVID-19 transmission in the operating rooms, but the possibility that operating staff were exposed to severe acute respiratory syndrome coronavirus 2（SARS-CoV-2）cannot be ruled out. We were able to accept all requests from various surgical departments regardless of their emergency status. Thus, our operating rooms remained as functional as they were before the COVID-19 pandemic.

A 28-year-old pregnant woman at 29 weeks and 4 days of gestation underwent emergent open appendectomy under combined spinal-epidural anesthesia because of possible cesarean section. Frequent uterine contraction was noted after surgery, and continuous infusion of ritodrine 150 μg/min was started to prevent uterine contraction and increased to 200 μg/min on postoperative day 1. Pulmonary edema occurred two days after surgery and was relieved by ceasing ritodrine infusion and restricting infusion volume. She was discharged and a full-term delivery was achieved without complications.

Patients undergoing surgery experience postoperative pain to varying degrees. Postoperative pain usually subsides spontaneously over a period of days or weeks as the wound heals. Depending on the patient, pain persists for several months to several years after the operation, resulting in a condition called “chronic postoperative pain”. Chronic postoperative pain has been listed as a disease name in the WHO International Classification of Diseases（ICD-11）. It is necessary to consider how to deal with acute, subacute, and chronic postoperative pain. In Japan, no guideline that comprehensively captures postoperative pain has been issued yet. We believe that it is necessary to expedite this publication as soon as possible, and we would like to support the promotion of seamless postoperative pain control from the preoperative period to the chronic stage. Here, we would also like to discuss the significance of publishing a postoperative pain guideline.

Perioperative neurocognitive disorders（PND）, now encompassing postoperative cognitive dysfunction（POCD）and delirium, are major challenges to our rapidly growing aging population and negatively affect cognitive domains such as memory, attention, and concentration after surgery. POCD is the most frequently reported form of brain injury in the cardiovascular surgery setting. Cardiopulmonary bypass（CPB）was long thought to be the main cause of POCD, but recent studies reveal that POCD has a similar incidence regardless of whether CPB is performed during the surgical procedure. To reduce the occurrence of PND in cardiovascular surgery patients, it is important to implement brain protection strategies and a multidisciplinary approach to promoting postoperative recovery.

Postoperative mortality rate has been decreased, and postoperative outcomes are increasingly focused on patient-oriented outcomes such as quality of life and functional recovery. Postoperative delirium has received particular attention because of its impact on postoperative outcome after hospital discharge. Undiagnosed preoperative cognitive impairment, in addition to aging and frailty, has been identified as a risk factor. Intraoperative and postoperative efforts should be made to avoid hypotension and to manage inflammation, including appropriate pain relief. In addition, although postoperative evaluation is not adequately performed by anesthesiologists, efforts should be made to assess for postoperative delirium using appropriate tools.

The impact of volume expansion varies depending on a patient’s state. This is referred to as "Context-sensitive" and is one of the most essential principles in perioperative fluid management. Recently, endothelial glycocalyx has gained attention as a factor which can influence this principle. Endothelial glycocalyx plays an important role in maintaining vascular permeability, and the Revised Starling’s principle, which takes the endothelial glycocalyx into account, is helpful for understanding the mechanism of context-sensitive volume loading. Considering that clinical condition differs widely among surgical patients, intraoperative fluid management should not be generally considered, but rather tailored depending on the condition of each patient. This mini-review outlines the current understanding of “Context-sensitive” volume loading and considers its clinical implications depending on the condition of surgical patients.

The goal of perioperative fluid management among anesthesiologists is to maintain cardiac output and tissue perfusion pressure in order to minimize perioperative complications. The importance of optimal fluid management without excessive or inadequate volume replacement has been widely recognized in clinical practice, following deeper understanding of the association between perioperative fluid volume and postoperative complications. Dynamic variables such as stroke volume variation and pulse pressure variation have recently been used to optimize perioperative fluid management, particularly in severe cases. However, these dynamic variables show some limitations. Specifically, the reliability of dynamic variables decreases during arrhythmias, spontaneous breathing, and open thoracic procedures. A recent study reported that recruitment maneuver–induced stroke volume and blood pressure changes were good predictors of hemodynamic response even under conditions unfavorable to the accuracy interpretation of dynamic variables. Such additional intervention can effectively improve the predictability of infusion responsiveness. Anesthesiologists should be aware of the limitations of each dynamic variable and combine various parameters for optimal intraoperative fluid management.

Propofol-induced loss of consciousness correlates with the appearance of a synchronized alpha rhythm on the frontal cortical electroencephalogram. However, the detailed mechanism underlying the propofol-induced alpha-rhythm is not fully understood. Our multiple whole-cell patch-clamp recordings in rat cortical slices revealed that 1） propofol preferentially facilitated unitary inhibitory postsynaptic currents recorded from fast-spiking interneuron to pyramidal neuron connections；and 2） propofol-induced facilitation of unitary inhibitory postsynaptic currents resulted in firing synchrony among postsynaptic pyramidal neurons receiving presynaptic inhibitory inputs from their corresponding fast-spiking interneurons. Together with previous observations, our findings suggest that the synchronicity of pyramidal neurons in the cerebral cortex and well-coordinated thalamocortical alpha oscillation contributes to the alpha rhythm associated with propofol-induced loss of consciousness.

Ondansetron and granisetron（5-HT₃ receptor antagonists）have recently become available in Japan for prevention of postoperative nausea and vomiting（PONV）, which has expanded the range of therapeutic options for PONV prophylaxis. However, these agents have been used as first-line agents for PONV prophylaxis in other countries for over 20 years. Recent guidelines for the prevention and treatment of PONV recommend the administration of additional antiemetic agents with newer mechanisms of action. In this article, we discuss the role of aprepitant and amisulpride（antiemetic agents）, as well as olanzapine, which have shown good efficacy for PONV prophylaxis in recent clinical trials.